Treatment of Sacroiliac Joint Dysfunction. Movement of sacrum on ilium

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1 Treatment of Sacroiliac Joint Dysfunction Movement of sacrum on ilium

2 Sacroiliac Joint Axes Superior Middle Inferior Right Oblique Left Oblique

3 Sacroiliac Joint Movement Nutation: : Anterior nutation or flexion Counternutation: : Posterior nutation or extension Forward rotation around an oblique axis Backward rotation around an oblique axis

4 Sacroiliac Joint Movements Physiologic Left sacral torsion on left oblique axis Right sacral torsion on right oblique axis Bilateral anterior sacral nutation Bilateral posterior sacral nutation Anterior sacral nutation with exhalation Posterior sacral nutation with inhalation Non-physiologic Left sacral torsion on right oblique axis Right sacral torsion on left oblique axis Left unilateral anterior nutation Right unilateral anterior nutation Left unilateral posterior nutation Right unilateral posterior nutation

5 Sacral Nutation Sacral locking Base of sacrum moves into pelvis Inferoposterior glide of articular surface of sacrum on ilium Coronal axis of interosseous ligament Iliac bones approximate, ischial tuberosities spread Limited by interosseous,, ant. sacroiliac, sacrotuberous and sacrospinous lig Bilateral Early trunk extension End range trunk flexion Exhalation Unilateral Hip flexion

6 Sacral Counternutation Sacral unlocking Backward motion of base of sacrum out of pelvis Anterosuperior glide of articular surface of sacrum on illium Coronal axis of interosseous ligament Iliac bones spread, ischial tuberosities approximate Limited by long post sacroiliac ligament and multifidus contraction Bilateral Early trunk flexion End of trunk extension Inhalation Unilateral Hip extension

7 Reciprocal Movement at Lumbosacral Junction Flexion of L5S1 Sacral base moves posteriorly into extension (counternutates) Extension of L5S1 Sacral base moves anteriorly into flexion (nutates) Right rotation and left sidebending of L5 Sacral base rotates to left and side bends right

8 Muscle Functions Piriformis Anterior tilt and rotate sacrum to opposite side Assisted by ipsilateral gluteus maximus Contralateral latissimus dorsi and gluteus maximus through LDF Nutation of sacrum and extension of LS junction Long head of biceps Backward tilt and rotate sacrum to same side Longissimus and multifidus Pull sacral base superiorly and posteriorly thru dorsal ligaments

9 Normal Gait Mechanics Innominate Right innominate rotates anteriorly Sacrum rotates toward it and sidebends away from it Sacrum L5 Sacrum moves into right forward torsion on right oblique axis the returns to neutral As sacrum right rotates and left sidebends,, L5 left rotates and right sidebends

10 Pelvic Girdle Function Form closure Bones, joints, ligaments Force closure Muscles, fascia Motor control Neural patterning Emotions Awareness Lee

11 Impairments Excessive articular compression Fusion (AS) Capsular fibrosis Overactivation of global myofascial system Joint fixation (underlying instability) Insufficient articular compression Ligamentous laxity Underactivity of local myofascial system Lee

12 Somatic Dysfunction Function Stability and motion of SI joints result of shape of joint surfaces (form closure) and altering of ligamentous tension in response to changes of muscle tone (force closure) (Isaacs & Bookhout) Dysfunction Imbalance of tension and tone between muscles and ligaments which locks SI joint and prevents normal function (Isaacs & Bookhout) ARTT Asymmetry of position, restricted motion, tissue texture, tenderness

13 Sacroiliac Somatic Dysfunctions Forward sacral torsion Backward sacral torsion Bilateral sacral anterior nutation Bilateral sacral posterior nutation Unilateral sacral anterior nutation Unilateral sacral posterior nutation

14 Symptoms Stiffness and pain with walking Pain opposite side with walking SI Pain same side with walking IS Unilateral pain below L5 Pain with sit to stand Coccydynia (torsions) Groin pain

15 Examination Positional tests Motion tests Passive mobility tests Pain provocation tests Palpation

16 Positional Tests Landmarks ASIS PSIS Sacral sulcus ILA Medial malleoli (prone) L5 Pubic tubercle Positions Neutral, extended and flexed

17 Active Motion Tests Standing flexion test Stork test Gillet s test Seated flexion test Piedallu s test

18 Passive Mobility Testing Osteokinematic Nutation/counternutation Prone Anterior/posterior innominate rotation Sidelying Arthrokinematic Inferoposterior glide Anterior innominate rotation Superoanterior glide Posterior innominate rotation Horizontal translation Squish test Vertical translation Lumbar spring test

19 Palpation Tension (ligaments) Sacrotuberous Long dorsal ligament Tone (muscles) Piriformis Psoas/Iliacus Coccygeus Gluteus maximus Latissimus dorsi Multifidus Erector spinae Tenderness

20 Tenderness L5S1 yellow Lumbar black SI joint - blue

21 Pain Provocation Tests Anterior gapping (Distraction) Posterior gapping (Compression) Gaenslen s Thigh thrust Sacral thrust

22 Standing Anatomic landmarks Standing flexion test Symmetrical superior movement of PSIS s Stork test (Gillet( Gillet s march test) PSIS should drop (also move laterally after 90 ) Hip drop test Anterior nutation on side of bent knee, rotate toward lumbar concavity Side bending Anterior nutation on side of convexity, rotate toward lumbar concavity Anterior innominate rotation (side of concavity), posterior innominate rotation (side of convexity)

23 Seated Seated forward flexion test Symmetrical superior/anterior movement of PSIS s Positive seated flexion test indicates sacroiliac dysfunction Indicates dysfunctional side Palpation ILA s Symmetrical in upright, flexed and extended positions Lumbar laminae (L5) and transverse processes Symmetrical

24 Seated Flexion Test If ILA s become symmetrical Rule out Unilateral anterior or posterior sacral nutations Forward sacral torsion If positive on left Rule out Bilateral anterior or posterior nutations Could be Left unilateral anterior nutation ROR forward sacral torsion LOR backward sacral torsion

25 Supine Palpate ASIS s,, pubic tubercles, medial malleoli Helps define etiology Is it purely sacral or mixed problem (iliac and pubic dysfunction) Squish test Symmetrical resistance Pain provocation tests Gaenslen s test SI compression/distraction Compression in sidelying Thigh thrust ASLR (Active SLR test)

26 Prone Palpation Sacral base and ILA s Prone and prone-on elbows positions Malleoli position Long dorsal sacroiliac joint ligament Sacrotuberous ligament Muscles Piriformis, gluteal, paraspinal Mobility Spring test Lumbar Sacral (transverse axis & oblique axis) Pain provocation test Sacral thrust

27 Forward Sacral Torsion Forward rotation around oblique axis 85% LOL (common in R handed people) Imbalance between piriformis and hip rotator muscles. After posterolateral disc. Symptoms No low back pain, unless associated with ERS Piriformis symptoms, gluteal pain Occasional sciatica Standing, walking and stair climbing Little or no pelvic restriction with gait In gait, on R heel strike, sacrum turns L and L5 turns R At R mid-stance, sacrum rotates right on ROA, L5 rotates L and SB R Must treat lumbar non-neutral neutral dysfunctions first

28 Backward Sacral Torsion Backward rotation around oblique axis 85% LOR Lumbar sidebending and rotation to same side while fully flexed. Locks with attempt to return to upright position. Left L/S SB/ROT in F will cause right sacral rotation on LOA the well bent over and the cripple stood up syndrome Symptoms: Testicle pain, heel burning, lateral knee pain, back of leg numb; can t t lie side of torsion; can t t lie prone; morning stiffness; inability to cross legs; inability to sweep or vacuum; pain with walking; sit-to to-stand; rising from FB position Must treat non-neutral neutral lumbar dysfunction first

29 Sacral Torsion Diagnosis Sulcus deep and ILA posterior on opposite sides Sulcus determines torsion Left sulcus deep is RST Axis and direction determination Piriformis Left tight creates ROA Positive left seated flexion test indicates tight left piriformis Spring test positive in backward, negative in forward Forward torsions become asymmetric in flexion and symmetric in extension (ILA( ILA s) Backward torsions become asymmetric in extension and symmetric in flexion (ILA( ILA s) Normal lumbar adaptation ROT in direction of deep sulcus,, SB away

30 Sacral Torsions

31 Bilateral Anterior Sacral Nutation Also known as bilaterally flexed sacrum or bilateral inferior sacral shear Forward rotation on MTA Rare Jumping from a height and landing Symptoms: Persistent lumbosacral and gluteal pain Lumbosacral/gluteal pain worse with forward bending, walking, standing, down stairs Prefers to lie prone Stands with accentuated lordosis Uncomfortable sitting Lumbosacral flexion limited

32 Bilateral Posterior Sacral Nutation Also known as bilaterally extended sacrum or bilateral superior sacral shear Backward sacral rotation on MTA Lifting heavy load in midline position Symptoms: Constant lumbosacral pain Lumbosacral pain worse with backward bending, sit-to to-stand, walking down stairs, patient prefers to sit slumped with arms on thighs, lie supine or fetal position, stands with flat back Lumbosacral extension limited

33 Bilateral SI Dysfunctions

34 Unilateral Anterior Sacral Nutation Also known as inferior sacral shear, unilateral flexed sacrum or side bent lesion Usually traumatic Land on one leg with spine extended (volleyball/basketball) Superior transverse axis Associated with posterior innominate rotation and non-neutral neutral L5 dysfunction (L innominate posterior rotation with L5 ERSL) Treat L5 dysfunction first Less common than torsions 3:2, left flexion most common Symptoms Pain usually in sacral and gluteal areas, unilateral Ipsilateral sciatica Gait problem, pain opposite side Worse with standing (<20 min) Relieved by sitting Tests for sacral sulci and ILA s definitive

35 Unilateral Posterior Sacral Nutation Also known as superior sacral shear or unilateral sacral extension Superior transverse axis Rare, most common on right May be associated with anterior innominate dysfunction May be confused with R on L torsion Caused by bending and twisting followed by forceful extension with load. Hypertonus of ipsilateral longissimus thoracis as result of thoracolumbar area strain Often treating source of hypertonus (TL junction) fixes problem Sometimes must treat L5 (FRSR)

36 Unilateral Sacral Nutation Diagnosis Sulcus deep and ILA inferior/posterior on same side (anterior nutation) Flexed and extended positions ILA s never become symmetric with unilateral nutations Seated flexion test Positive on left with left anterior nutation Normal lumbar adaptation ROT in direction of deep sulcus,, SB away

37 Unilateral SI Dysfunctions

38 Treatment Muscle energy Joint mobilization Joint manipulation Muscle stretching Trunk stabilization

39 Correction of Forward Sacral Torsion Lie axis side down Rotate trunk to right with right arm off table Flex knees and hips to localize forces at L/S junction Resist bottom heel lifting toward ceiling ROR

40 Correction of Backward Sacral Torsion Lie axis side down Extend lower leg to induce some sacral flexion Flex upper hip so leg off table Extend trunk to L/S junction Rotate trunk left to L/S junction Resist lifting upper leg toward ceiling LOR

41 Correction of Bilateral Anterior Nutated Sacrum Patient seated Feet apart and legs internally rotated Patient flexes forward ATC hands on sacral apex and thoracic spine Maintain pressure on sacral apex (ILA( ILA s) ) and resist trunk extension with full inhalation

42 Correction of Bilateral Posterior Nutated Sacrum Patient seated Feet together and legs externally rotated Arms crossed ATC hands on sacral base and across anterior chest Maintain pressure on sacral base and resist trunk flexion with full exhalation or have patient arch back by pushing abdomen to knees

43 Correction of Unilateral Anterior Sacral Nutation Patient prone Abduct (15 ) ) and internally rotate left leg ATC s right hand on left ILA Apply and maintain anterior and superior pressure on left ILA as patient inhales and holds breath ATC maintains pressure as patient exhales Left Unilateral Anterior Nutation

44 Correction of Unilateral Posterior Sacral Nutation Patient prone Abduct (15 ) ) and externally rotate right leg Trunk extended via prone on elbow position ATC s right hand on right sacral base Apply and maintain anterior and inferior pressure with right hand as patient exhales ATC s left hand applies posterior pressure to right ASIS After exhalation, patient pulls ASIS toward table Return to prone lying position while maintaining pressure Right Unilateral Posterior Sacral Nutation

45 Treatment Sequence Lumbar spine, pubes, innominate shears, sacroiliac dysfunction, iliosacral dysfunction, muscle imbalances (Greenman( Greenman) Pubes, innominate shears, lumbar spine, sacroiliac dysfunction, iliosacral dysfunction (Issacs( & Bookhout) Leg muscles, pubes, iliosacral (flares, innominate shears, rotations), sacroiliac, lumbar (unless L5, then before sacrum) (Rex) Pubes, iliosacral (rotations, innominate shears, flares) sacroiliac (Mitchell)

46 References Issacs ER, Bookhout MR. Bourdillon s Spinal Manipulation (6 th Ed.). Butterworth- Heinemann:Boston,, 2002 Greenman PE. Principles of Manual Medicine (3 rd Ed.). Lippincott Williams & Wilkins:Philadelphia,, 2005 Lee D. The Pelvic Girdle (3 rd Ed.). Churchill Livingstone:Edinburgh,, 2004 Rex L. Ursa Foundation, Edmonds, WA.